Provider Demographics
NPI:1932807476
Name:ANDERSON, LACY (CBD, CPD)
Entity Type:Individual
Prefix:
First Name:LACY
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:CBD, CPD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19843 US HIGHWAY 41 W
Mailing Address - Street 2:
Mailing Address - City:CHAMPION
Mailing Address - State:MI
Mailing Address - Zip Code:49814-9519
Mailing Address - Country:US
Mailing Address - Phone:906-458-5678
Mailing Address - Fax:
Practice Address - Street 1:19843 US HIGHWAY 41 W
Practice Address - Street 2:
Practice Address - City:CHAMPION
Practice Address - State:MI
Practice Address - Zip Code:49814-9519
Practice Address - Country:US
Practice Address - Phone:906-458-5678
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-22
Last Update Date:2023-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula